How-to Guide: Reducing Patient Injuries from Falls

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1 Updated December 2012 How-to Guide: Reducing Patient Injuries from Falls This How-to Guide was initially developed as part of the Transforming Care at the Bedside (TCAB) initiative. TCAB was a national effort of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement designed to improve the quality and safety of patient care on medical and surgical units, to increase the vitality and retention of nurses, and to improve the effectiveness of the entire care team. For more information, go to or Copyright 2012 Institute for Healthcare Improvement All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement. How to cite this document: Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D, Rita S. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; Available at:

2 Acknowledgements Financial support for this publication was provided through grants from the Robert Wood Johnson Foundation for two national programs implemented by the Institute for Healthcare Improvement: Transforming Care at the Bedside and the Falls Prevention Initiative. The Robert Wood Johnson Foundation (RWJF) focuses on the pressing health and health care issues in the US. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change. For more than 30 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. The Institute for Healthcare Improvement (IHI), an independent not-for-profit organization based in Cambridge, Massachusetts, is a leading innovator in health and health care improvement worldwide. At our core, we believe everyone should get the best care and health possible. This passionate belief fuels our mission to improve health and health care. For more than 25 years, we have partnered with a growing community of visionaries, leaders, and front-line practitioners around the globe to spark bold, inventive ways to improve the health of individuals and populations. To advance our mission, IHI is dedicated to optimizing health care delivery systems, driving the Triple Aim for populations, realizing person- and family-centered care, and building improvement capability. Transforming Care at the Bedside Faculty and Authors Barbara Boushon, RN, BSN, Director/Faculty, Institute for Healthcare Improvement Institute for Healthcare Improvement,

3 Gail A. Nielsen, BSHCA, RTR, Director Learning and Innovation, Iowa Health System Center for Clinical Transformation; George W. Merck Fellow and Faculty, Institute for Healthcare Improvement Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Associate Chief, Nursing Service for Research; Associate Director, VISN 8 Patient Safety Center of Inquiry Suzanne Rita, RN, MSN, Improvement Learning Network Manager, Iowa Health System Center for Clinical Transformation Pat Rutherford, MS, RN, Vice President, Institute for Healthcare Improvement Diane Shannon, MD, MPH, Medical Writer Jane Taylor, EdD, Improvement Advisor, Institute for Healthcare Improvement Contributors IHI acknowledges the pioneering work of the teams from the following hospitals in testing new approaches to reduce serious patient injury from falls: Iowa Health System Hospitals (Iowa Health Des Moines, Iowa;; St. Luke s Hospital Cedar Rapids, Iowa; Trinity Medical Center Rock Island, Illinois); James A. Haley Veterans Hospital Tampa, Florida; Kaiser Permanente Roseville Medical Center Roseville, California; North Shore Long Island Jewish Health System (Long Island Jewish Medical Center New Hyde Park, New York; North Shore University Hospital Manhasset, New York); Madison Patient Safety Collaborative Madison, Wisconsin; Sentara Healthcare Hospitals (Sentara Norfolk General Hospital Norfolk, Virginia; Sentara Virginia Beach General Hospital Virginia Beach, Virginia); Spaulding Rehabilitation Hospital Boston, Massachusetts; United Hospital Allina Hospitals & Clinics St. Paul, Minnesota; The University of Texas MD Anderson Cancer Center Houston, Texas; Seton Northwest Hospital and Seton Healthcare Network Austin, Texas. How to Cite This Document: Boushon B, Nielsen G, Quigley P, Rita S, Rutherford P, Taylor J, Shannon D, Rita S. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; Available at: Institute for Healthcare Improvement,

4 Introduction Launched in 2003, Transforming Care at the Bedside (TCAB) was a national program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI) that engaged leaders at all levels of the health care organization to: Improve the quality and safety of patient care on medical and surgical units Increase the vitality and retention of nurses Engage and improve the patient s and family members experience of care Improve the effectiveness of the entire care team The pilot program lasted five years and included 10 hospitals that worked to dramatically improve performance in the five TCAB themes: Transformational Leadership Safe and Reliable Care Vitality and Teamwork Patient-Centered Care Value-Added Care Processes At completion of the pilot TCAB program, the ten hospitals had created and tested new concepts, developed exemplary care models on medical and surgical units, demonstrated institutional commitment to the program, and pledged resources to support and sustain these innovations. Since then, more than 70 hospital teams across the United States have joined these ten initial participants in applying TCAB principles and processes to dramatically improve the quality of patient care on medical and surgical units through IHI Collaboratives. Sixty-seven hospitals have participated in the American Organization of Nurse Executives (AONE) TCAB program. For more information on TCAB programs and participating sites, please see the following: IHI TCAB initiative website (background, team stories, examples, and tools) RWJF TCAB Toolkit AONE TCAB program website Institute for Healthcare Improvement,

5 The How-to Guide: Reducing Patient Injuries from Falls presents a promising new approach developed within the Transforming Care at the Bedside (TCAB) initiative. In 2006, eight hospitals with strong leadership commitment to a culture of innovation and a special interest in reducing injury from falls received RWJF grants to test, and measure comprehensive changes aimed at reducing patient injury from falls on medical and surgical units. In 2007, these hospitals continued to test innovations in falls and injury prevention in hospitals through a second IHI Falls Collaborative. During this time, key components for reducing falls-related injuries were specified for organization-level and unit-level programs. Unit-level strategies focused on assessment, intervention, and communication about fall risks, injury risks, and management. While built upon the best known strategies, standards of care, advances in innovation, and science and program management for reducing falls among hospitalized patients, this How-to Guide adds a specific approach to the current thinking on falls prevention: the creation of customized interventions to prevent falls and subsequent injuries for the patients who are at most risk for serious injuries from a fall. Other useful resources and toolkits on falls prevention include: ECRI Falls Prevention Resources VA National Patient Safety Center Falls Prevention Toolkit Joint Commission Resources, Preventing Patient Falls Minnesota Hospital Association SAFE from FALLS VISN 8 Patient Safety Center of Inquiry Falls Team Institute for Healthcare Improvement,

6 The Case for Reducing Patient Injuries from Falls Falls represent a major public health problem around the world. In the hospital setting, falls continue to be the top adverse event. Injuries from falls are never events that are associated with morbidity and mortality, and which also impact reimbursement. Some 3 to 20 percent of inpatients fall at least once during their hospitalization. Injury prevalence ranges from 30 to 51 percent. Of these, 6 to 44 percent experience similar types of injury (e.g., fracture, subdural hematomas, excessive bleeding) that may lead to death. Adjusted to 2010 dollars, one fall without serious injury costs an additional $3,500, while patients with >2 falls without serious injury have increased costs of $16,500. Falls with serious injury are the costliest, with additional costs of $27,000. Many interventions to prevent falls and fall-related injuries have been tested, but require multidisciplinary support for program adoption and reliable implementation for specific at risk and vulnerable subpopulations, such as the frail elderly and those at risk for injury. All efforts must be made to ensure that patient safety programs are in place across settings of care. For example, the elderly who are at risk for falls and injury while in the hospital are also at risk for such injuries once they transition into long-term care settings, so patient safety programs must be in place in both settings. Injurious falls are more likely to occur among nursing home residents due to advanced age, multiple comorbidities (e.g., dementia and osteoporosis), and multiple prescription medications that negatively affect gait and balance and even bone strength. Falls among nursing home residents occur frequently and repeatedly. Among published studies of falls in nursing homes, the mean number of falls per bed per year was approximately 1.5, with a range of 0.2 to 3.6. About 35 percent of these fall-related injuries occurred in residents who were non-ambulatory (e.g., used wheelchair for mobility). A considerable body of literature exists on falls prevention and reduction. Successful prevention strategies include risk screening, multifactorial assessment (estimating danger of falling based on known intrinsic and extrinsic factors), interventions (preventive action to modify and compensate for risk factors), and systematic reporting Institute for Healthcare Improvement,

7 of falls incidents and their consequences. Oliver and colleagues (2010, p. 685) recommend that fall and injury prevention programs follow four key approaches: 1) implementation of safer environment of care for the whole patient cohort (e.g., flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear); 2) identification of specific modifiable fall risk factors; 3) implementation of interventions targeting those (modifiable) risk factors so as to prevent falls; and 4) interventions to reduce risk of injury to those people who do fall. Oliver D, Healey F, Haines T. Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine. 2010;26(4): Wu S, Keeler E, Rubenstein L, et al. A cost-effectiveness analysis of a proposed national falls prevention program. Clinics in Geriatric Medicine. 2010;26(4): van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. Journal of the American Geriatrics Society. 2003;51(9): Thapa PB, Brockman KG, Gideon P, et al. Injurious falls in non-ambulatory nursing home residents: a comparative study of circumstances, incidence and risk factors. Journal of the American Geriatrics Society. 1996;44(3): Additional references of interest: Brainsky GA, Lydick E, Epstein R, et al. The economic cost of hip fractures in community dwelling older adults: A prospective study. Journal of the American Geriatrics Society. 1997;45: Buckwalter KC, Cutillo-Schmitter TA. Fall prevention for older women. Women s Health in Primary Care. 2004;7: Centers for Disease Control and Prevention. Hip fractures among older adults. Available at: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Older adults falls publications. Available at: Donaldson N, Brown, DS, Aydin CE, Bolton MI, Rutledge DN. Leveraging nurse-related dashboard benchmarks to expedite performance improvement and document excellence. Journal of Nursing Administration. 2005;35(4): Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Sciences. 1996;41(5): Fife D, Barancik JI. Northeastern Ohio Trauma Study III: Incidence of fractures. Annals of Emergency Medicine Mar;14(3): Fonda D, Cook J, Sandler V, Bailey M. Sustained reduction in serious fall-related injuries in older people in hospital. The Medical Journal of Australlia. 2006;184: Hamerlynck JV, Middeldorp S, Scholten RJ. [From the Cochrane Library: Effective measures are available to prevent falls in the elderly.] Ned Tijdschr Geneeskd. 2006;150(7): Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final data for National Vital Statistics Reports Jun;47(19): Institute for Healthcare Improvement,

8 Jacoby SF, Ackerson TH, Richmond TS. Outcome from serious injury in older adults. Journal of Nursing Scholarship. 2006;38(2): Lancaster AD, Ayers A, Belbot B, et al. Preventing falls and eliminating injury at Ascension Health. Joint Commission Journal on Quality and Patient Safety Jul;33(7): Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M, Felsenthal G, Kenzora J. Recovery from hip fracture in eight areas of function. Journals of Gerontology Series A: Biological Sciences and Medical Sciences Sep; 55(9):M498-M507. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions for the prevention of fall related injuries in older people. Cochrane Database of Systematic Reviews Jan 25;(1):CD Rivara FP, Grossman DC, Cummings P. Medical progress: Injury prevention (second of two parts). New England Journal of Medicine. 1997;337: Schwendimann R. Prevention of falls in acute hospital care: Review of the literature. Pflege. 2000;13: Tinetti ME, Williams CS. Falls: Injuries due to falls and the risk of admission to a nursing home. New England Journal of Medicine. 1997;337: Can We Eliminate Serious Injury from Falls for Hospitalized Patients? Despite the growing body of literature that supports the effectiveness of falls reduction programs, there is a relative paucity of information on identifying patients at highest risk for sustaining serious injury from a fall and on interventions to prevent such injuries. At present, no tool exists to guide nurses and other care team members in assessing risk for injury from a fall. However, the literature does identify patient populations at greatest risk for injury from falls, including individuals 85 years of age or older, patients with osteoporosis, and patients taking anticoagulants. This How-to Guide can help health care staff learn to identify patients at highest risk for sustaining a serious injury from a fall and implement interventions to prevent or mitigate these injuries. Both physical injury (such as hip fracture) and emotional harm (such as subsequent fear of falling) can occur as a result of a fall. While acknowledging the emotional harm that may result from repeated falls or from falls with no apparent injury, this guide focuses on approaches to reduce physical injury associated with patient falls that occur on inpatient units. Institute for Healthcare Improvement,

9 The How-to Guide is divided into three sections: Section One highlights six promising changes designed to reduce serious injuries from falls for hospitalized patients. It also includes references and links to helpful resources. Section Two outlines practical step-by-step activities for testing, adapting, and implementing the proposed changes described in Section One. Section Three includes resources and tools from hospitals engaged in fall prevention work. Section One This section highlights six promising changes designed to reduce serious injuries from falls for hospitalized patients. Key references and links to helpful resources are also included, where available. 1. Screen risk for falling on admission a. Perform standardized fall risk screen for all patients on admission (anticipated physiological falls) b. If over 65 years of age, ask about history of falls upon admission. Use time interval (e.g., in past 12 months) based on your screening tool. 2. Screen fall-related injury risk factors and history upon admission a. Screen for risk factors for serious injury (history of osteoporosis, risk factors or fracture, presence of anticoagulation/bleeding problems) b. Ask about history of fall-related injuries upon admission: history of fractures, history of head trauma, history of uncontrolled bleeding after a fall, and history of hospitalizations due to a fall 3. Assess multifactorial risk of anticipated physiological falling and risk for a serious or major injury from a fall a. For positive risk screens, complete in-depth multifactorial fall risk assessment with an interdisciplinary team for all patients on admission and whenever patients clinical status changes. b. Communicate and identify at every shift the patients most at risk of moderate to serious injury from a fall. Institute for Healthcare Improvement,

10 4. Communicate and educate about patients fall and injury risks a. Communicate to all staff information regarding patients who are at risk of falling and at risk of sustaining a fall-related injury. Communicate changes in risk for injury from a fall (i.e., started on anticoagulation or new diagnosis of osteoporosis during pre-shift and handoff). Use signage to identify those patients who are "known fallers" (admitted due to a fall or have experienced a fall during this episode of care), at risk for injury, or who have a history of prior fall-related injury. b. Use Teach Back to educate the patient and family members about risk of injury from a fall on admission and throughout the hospital stay, and about what they can do to help prevent a fall. 5. Standardize interventions for patients at risk for falling a. Implement both hospital-wide and patient-level improvements to the patient care environment to prevent falls and reduce severity of injury from falls. b. Perform rounding (every one to two hours) to assess and address patient needs for pain relief, toileting, and positioning. 6. Customize interventions for patients at highest risk of a serious or major fall-related injury a. Increase the intensity and frequency of observation. b. Make environmental adaptations and provide personal devices to reduce risk of fall-related injury. c. Target interventions to reduce the side effects of medications. 1. Screen risk for falling on admission 1a. Perform standardized fall risk screen for all patients on admission (anticipated physiological falls). Use a fall risk screening tool that has been validated to predict the likelihood of anticipated physiological falls. This type of fall is predicated on intrinsic and extrinsic risk factors known through empirical evidence to contribute to a fall occurring. A review of the predictive validity of fall risk screening scales is provided by Oliver and colleagues (2010). Oliver D, Healey F, Haines T. Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine. 2010; 26: Ask the patient and/or family about immediate history of falls and falls within the last three to six months. Institute for Healthcare Improvement,

11 1b. If over 65 years of age, ask about history of falls upon admission. Use the time interval (e.g., in the past 12 months) based on your screening tool. 2. Screen fall-related injury risk factors and history upon admission 2a. Screen for risk factors for serious injury. Upon admission, ask the patient and/or family screening questions about risk factors for serious injury, specifically fractures or bleeding. For fractures, complete a patient history about osteoporosis risk factors (e.g., history of smoking, steroid use, alcohol use, chemotherapy, etc.), positive diagnosis of osteoporosis, and any history of fracture. Next, determine if the patient is at risk for bleeding: presence of anticoagulation/bleeding problems, and/or platelet disorders. 2b. Ask about history of fall-related injuries upon admission: history of fractures, history of head trauma, history of uncontrolled bleeding after a fall, and/or history of hospitalizations due to a fall. After a positive screen (from steps 1 and 2), the next step is to complete an assessment (step 3). The screening questions will serve as the basis for a focused and comprehensive assessment. 3. Assess multifactorial risk of anticipated physiological falling and risk for a serious or major injury from a fall Complete this multifactorial risk assessment for all patients on admission and whenever a patient s clinical status changes. For positive risk screens, complete an in-depth multifactorial injury risk assessment with an interdisciplinary team for all patients on admission and whenever a patient s clinical status changes. Accurate and insightful assessment of all patients fall and injury risks on admission and throughout the hospital stay is a critical step in developing and implementing Institute for Healthcare Improvement,

12 customized and timely interventions to prevent falls and reduce the severity of fallrelated injuries. Typical failures associated with patient assessment include the following: Failure to recognize the limitations of the falls risk screening tools Lack of a standardized or reliable process for comprehensive fall risk assessment Lack of identification of patients at increased risk for a fall-related injury Lack of expertise in administering the assessment after positive risk screening Late administration of multifactorial and interdisciplinary assessment Lack of procedure for or time to consistently reassess change in patient condition Lack of clarity in expectations regarding patient assessment Failure to intervene quickly and link interventions to specific assessed risk factors Failure to reassess risk during patients entire hospital stay 3a. For positive risk screens, complete an in-depth multifactorial fall risk assessment with an interdisciplinary team for all patients on admission and whenever a patient s clinical status changes. Ideally, nurses assess fall risk at critical times during a patient s hospital stay, not only on admission. When nurses switch at shift change, when patients transfer between departments, and when a patient s status or treatment changes, it is important to consider whether the patient s condition has changed and review the risk for falls. Ensure that staff completely understand the correct administration and interpretation of the scales, routinely administer the scales upon admission, and quickly implement appropriate interventions based on assessment results. Use nursing judgment and critical thinking skills to occasionally override the results of the assessment scales. If a nurse believes that a patient is at risk for falling, appropriate interventions should be implemented regardless of the Institute for Healthcare Improvement,

13 assessment results. A few hospitals use an adapted assessment scale that captures the nurse s critical thinking. A 2010 Clinics in Geriatric Medicine article provides an evidenced-based review of fall risk assessments. Oliver D, Healey F, Haines T. Preventing falls and fall-related injuries in hospitals. Clin Geriatric Medicine. 2010; 26: Assess patients for fall risk and risk of injury from a fall. Hospitals have approached assessment in different ways: o A few teams integrated information from the patient s family into the fall risk assessment process by asking family members about the actions they take at home to keep the patient safe from falling. o Some hospitals added the injury risk assessment to their traditional fall risk assessment form. The combined assessment increases process reliability and helps staff remember to evaluate the patient for both types of risk throughout the hospital stay. o Some hospitals partnered with the nursing homes, home care agencies, and rehabilitation centers from which their patients are admitted to identify effective protective devices and techniques for each patient referred. 3b. Communicate and identify at every shift the patients most at risk of moderate to serious injury from a fall. The literature and hospital-based exploration of fall-related injury suggest that the following groups of patients are most at risk for injury if they sustain a fall: Individuals who are 85 years old or frail due to a clinical condition Patients with bone conditions, including osteoporosis, a previous fracture, prolonged steroid use, or metastatic bone cancer Patients with bleeding disorders, either through use of anticoagulants or underlying clinical conditions Post-surgical patients, especially patients who have had a recent lower limb amputation or recent, major abdominal or thoracic surgery Institute for Healthcare Improvement,

14 Simple reminders, such as the example below, can help identify patients who may be at risk for injury from a fall. Staff can use the ABCS assessment at the beginning of each shift to identify the three to five patients on the unit who are most at risk of fall-related injury. Once these at-risk patients are identified, staff can implement interventions to reduce risk of fall-related injury and address specific patient needs in the care plan. A = Age or frailty B = Bones (fracture risk or history) C = anticoagulation (bleeding disorder) S = recent Surgery (during current episode of care) 4. Communicate and educate about patients fall and injury risks Dependable and consistent communication with patients and family members and among the entire care team is critical to preventing falls and reducing fall-related injuries. Tools for patient education, such as the Teach Back method, and strategies for improving staff communication, such as visual indicators and use of change of shift reports or rounds, are essential for any fall and injury prevention plan. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. Agency for Healthcare Research and Quality; (AHRQ Publication No. 01-EO58). Available at: Abrams MA, Hung LL, Kashuba AB, Schwartzberg JG, Sokol PE, Vergara KC. Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. Chicago: American Medical Association; Schillinger D, Piette J, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine Jan 13;163(1): Nielsen-Bohlman L, Panzer AM, Kindig DA (editors). Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; Available at: Typical failures associated with staff communication and patient and family education about risk for falls and fall-related injuries include: Failure to quickly communicate the results of a new or changed risk assessment and associated interventions Failure to incorporate and document prevention interventions in the patient care plan Institute for Healthcare Improvement,

15 Unclear or incomplete handoffs between departments and among staff within a department or unit Insufficient or unclear safety instructions Patient or family confusion about nurse teaching on safety instructions and precautions Incorrect assumption that the patient is the key or sole learner (family members should also be included) Delivery of safety education that fails to fit individual patient and family needs 4a. Communicate to all staff information regarding patients who are at risk of falling or at risk for sustaining a fall-related injury. Teams found that poor communication was a hazard and cause of patient harm in health care settings. When nurses on medical-surgical units understand a patient s potential for falling or injury from a fall, they will provide an appropriate level of care and targeted interventions. Studies in health literacy indicate that patients and family members who do not understand instructions do not tell the nurse about their confusion. Staff can use simple techniques to communicate level of risk to other staff members and to discern and address areas of patients and family misunderstanding. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MW. Shame and health literacy: The unspoken connection. Patient Education and Counseling. 1996;27: Focus on five: Strategies to improve hand-off communication. Joint Commission Perspectives. 2005:5(7):11. Use visual indicators to quickly communicate with the care team about patients at risk of fall or injury. For example, use colorful socks, colored wrist bands and/or blankets, or signage outside and inside the room to indicate fall and/or injury risk. Be careful to maintain patients dignity and respect their wishes about the use of visual identification of risk. Also, use judgment with use of visual aids. For example, if all your patients are at risk for falls, then use signage for only those patients at risk for injury, so as not to have a fall risk sign for every patient. If every patient has such signage, the signage no longer has meaning. Think about this in relation to universal infection control practices not every patient has a Institute for Healthcare Improvement,

16 sign that indicates "at risk to acquire an infection." So, use common sense and clinical judgment when considering communication, identification, and signage decisions. The following strategies have been adopted to help with specific communication about patients at greatest risk for falls or injuries: o At St. Luke s Hospital in Cedar Rapids, Iowa, magnetic fall precautions signs, which resemble street signs, protrude into the hallway to help nurses quickly identify the patients at greatest risk for falls or injuries. o At Trinity Regional Health System in Rock Island, Illinois, a yellow leaf posted outside the patient s door indicates the patient s risk for falling;; a red leaf indicates the patient also is at risk for injury from a fall. o At Sentara Healthcare in Virginia, patients at risk for falling and injury are given a small fleece lap blanket, color-coded to match the system-wide alert method that indicates patients at highest risk. When the patient is in a chair or wheelchair, the lap blanket is kept across the patient s legs. When in bed, the lap blanket is placed on top of the bedding. o At Kaiser Permanente Roseville Medical Center in California, a visual card (see below) is displayed at the doorway of patients who need assistance ambulating. The card clearly depicts the number of staff needed to support and protect both patients and staff, using color-coding to indicate the needed level of support. Example: Visual Cards Used at Kaiser Permanente Roseville Institute for Healthcare Improvement,

17 For patients at risk for injury but not identified as being at risk for falling: identify and communicate any changes in patient condition that may result in a risk for falling (e.g., patient on anticoagulation who is placed on sedatives). Ensure safe, standardized handoffs between nurses (e.g., at shift change) and communication with all unit staff and members of other departments. o Many teams added safety huddles at the beginning of each shift to identify and discuss the three to five patients believed to be at greatest risk for a fallrelated injury. Team members found the intervention especially helpful when a high proportion of patients on the unit were at risk for falling. Teams collected data on these patients to ascertain whether they sustained falls despite an escalation of interventions. Teams also tested new ideas for preventing these breakthrough falls. (Refer to Section Three for the Safety Huddle Form used at Trinity Health System in Illinois.) o At Sentara Health System in Virginia, nurses integrated information on patients risk for falling and injury into the shift handoff checklist. They discuss the patient s current condition, the effectiveness of previous interventions to prevent falls and fall-related injuries, and any currently interventions. (See Section Three for the Nursing Handoff Checklist and Worksheet, a sample shift report tool.) Institute for Healthcare Improvement,

18 4b. Use Teach Back to educate the patient and family members about risk of injury from a fall on admission and throughout the hospital stay, and about what they can do to help prevent a fall. Many teams found the Teach Back method helpful for assessing patient and family caregiver understanding of fall and injury risk and associated safety precautions. Teach Back is a patient education technique in which a patient or family caregiver recalls and restates, in their own words, the information they heard during education or other instructions. Teach Back also can be a repeat demonstration (i.e., how to use the call light). According to the patient safety literature, the Teach Back technique is one of the 11 most effective patient safety practices. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. Agency for Healthcare Research and Quality; (AHRQ Publication No. 01-EO58). Available at: Abrams MA, Hung LL, Kashuba AB, Schwartzberg JG, Sokol PE, Vergara KC. Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. Chicago: American Medical Association; Schillinger D, Piette J, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine Jan 13;163(1): Teach Back use by Transitions Home innovation units: Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at: ations.aspx. Use Teach Back to close understanding gaps between health care providers and the patient and family members and to highlight the fall prevention and injury reduction strategies. Teams found that including family members in the Teach Back process uncovered gaps in understanding about how to keep the patient safe in the hospital and at home. (See the Tips for Using Teach Back in Section Three.) Institute for Healthcare Improvement,

19 5. Standardize interventions for patients at risk for falling By assessing all patients for risk of falling and fall-related injuries, staff can identify a subset of patients at high risk of falling and sustaining a fall-related injury. Staff can then focus on providing a safe environment for these patients by implementing standardized processes that create and maintain a safe care environment. 5a. Implement both hospital-wide and patient-level improvements to the patient care environment to prevent falls and reduce severity of injury from falls. Improvements at both the hospital- and patient-level are essential to preventing falls and reducing fall-related injuries. Such improvements include: Creating a safe hospital environment by eliminating hazards (e.g., sharp edges, cluttered walkways, or raised thresholds) Providing safety aids (e.g., adequate lighting and non-slip flooring) Ensuring that every nurse takes responsibility for maintaining the safe hospital environment for every patient Establishing a standard process for specifying interventions based on individual patient needs Recommendations for planning and implementing these improvements include: Ensure that the unit champion for fall prevention performs an initial walk-through (and then quarterly walk-throughs) with hospital leaders to identify needed equipment, identify and eliminate environmental hazards, and identify needed renovations to the physical plant. o Use the walk-through technique to improve the safety of the physical plant. The hospital walk-through is most effective when conducted collaboratively with administration (e.g., associate directors and chiefs of services), support staff (e.g., environmental management and risk management), and clinical staff (e.g., nursing managers and staff nurses). Collaborative rounds are most effective because each member of the group provides a different perspective and ideas to improve safety. For example, facilities staff may notice a high threshold to the shower. Risk management personnel may suggest that grab- Institute for Healthcare Improvement,

20 bars are affixed between the patient bed and the bathroom. Working together, staff can identify opportunities to create a safer environment and ensure that relevant improvements are made and maintained. o Use a punch list or inventory for walk-throughs with facilities and risk prevention staff, paying special attention to toilet heights and weight limits, gradations in flooring, potentials sources of laceration (e.g., sharp edges on furniture or fixtures, and the presence or absence of grab bars). (See Sentara Healthcare s Environmental Fall Risk Assessment in Section Three.) Ensure that every nurse (and other hospital personnel who enter the patient room) assesses environment safety at every patient encounter. For example, nurses and other hospital staff should make it a habit to ensure that: o The call bell is within reach and visible o Personal care items are within easy reach o The bed is in the lowest position with wheels locked o The floor is free of clutter and trip hazards o Auditory alerts such as bed, chair, and personal alarms are turned to the On position o The wheels of bedside tables and cabinets are locked to prevent rolling Arrange the patient room to favor the patient s stronger or unaffected side or to create the shortest path to the bathroom. Room arrangements may involve moving the bed against a wall to allow egress from the side favoring the patient s stronger or unaffected side, or orienting the bed to minimize the distance to the bathroom or maximize the accessibility of hand rails. Check that all patient assistive equipment (e.g., walkers, wheelchairs, canes, and anti-tipping devices on wheelchairs) meets safety standards and is properly maintained. Reliably implementing this step may require collaboration with the physical or occupational therapy department, central purchasing and distribution, or the management team. Institute for Healthcare Improvement,

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